Resources sometimes fail mentally ill during times of crisis

Thursday

Mar 28, 2013 at 9:52 AM

Jim Jenkins is the exhausted father of an adult daughter with schizophrenia

By Molly ParkerMolly.parker@starnewsonline.com

Jim Jenkins is the exhausted father of an adult daughter with schizophrenia - a ruthless, insidious disease with no cure.He's sat in the emergency department in Brunswick Novant Medical Center at least 10 times."How many times has it been a good experience? I'm going to say none," said Jenkins, a Supply resident.The last time was in January 2011. The Southeastern Center for mental health (now CoastalCare), had successfully sought commitment papers early in the morning on his daughter, concerned that she was engaging in harmful behaviors, Jenkins said. Jenkins' daughter was picked up by police and escorted to Brunswick's emergency department - where Jenkins, his wife and daughter waited eight hours for her placement at a psychiatric hospital.Eventually a bed opened at Old Vineyard Behavioral Health Services in Winston-Salem, and his daughter was driven five hours - while in midst of a psychiatric emergency - in the back of a squad car. She was processed there in the early morning hours."Since we walked on the moon in 1969 you think there'd be an easier path to take care of someone who's mentally ill in 2013," Jenkins said.Long waitsA recent legislative oversight committee rang a loud warning about growing wait times in community emergency rooms for patients experiencing mental health crises. Advocates say this is a troubling trend because emergency rooms are often ill equipped to deal with psychiatric emergencies. Doctors are more often focused on matters of life and limb - not of the mind - in that helter-skelter environment."My feedback is that the ED docs aren't especially fond of our folks," said Loralie Grigas, a mental health and substance abuse counselor in private practice at Carolina Beach.Waiting only eight hours, the Jenkins family might have considered itself lucky, relatively speaking.Statewide, the average wait time for someone presenting with a mental health crisis at an emergency department is almost double that: 15 hours, 52 minutes, according to a Joint Legislative Oversight Committee on Health and Human Services, Subcommittee on Mental Health. That includes for those discharged to go home or be placed in a public or private psychiatric hospitalDon Dalton, spokesman for the N.C. Hospital Association, said it's a much longer wait in some cases, especially for hospital placement."We have people that stay in our emergency departments, three, five, seven and 10 ten days at a time waiting for inpatient care because there are not sufficient mental health beds in the state," he said.For placement in a state-run psychiatric hospital such as Cherry Hospital in Goldsboro, the closest option for Wilmington-area residents, the wait can be more than 70 hours. Construction is under way for an expanded Cherry Hospital to serve the eastern part of the state, which should help with wait times, said Julie Henry, spokeswoman for the N.C. Department of Health and Human Services.Options neededGrigas, a longtime mental health advocate, encourages development of a nonprofit organization where individuals can go for assessment that is not an emergency room. RHA Behavioral Health Services already offers a walk-in crisis clinic called Cape Fear Crisis Response Center, a facility for short-term overnight stays called The Harbor, and mobile crisis units in Wilmington. But Grigas said the feedback she hears is that it takes too long and the criteria for admission are unclear for The Harbor.So many people in crisis end up in emergency rooms, she said."It's not fair to the mental health patients, but it's not fair to the ED docs either, quite frankly," she said. "They are focused on what they are trained to do, which is dealing with medical emergencies. The mental health patients deserve to be a made a priority by folks trained to recognize and respond to a mental health crisis."RHA Behavioral Health did not return calls seeking comment.But Foster Norman, executive director of Coastal Care, said the primary issue is education - about folks knowing there are other, generally more efficient options to the emergency room."Our crisis response centers are the behavioral health equivalent of urgent care centers," he said, adding that anyone who shows up needing mental health care receives it.Further, he said, The Harbor recently increased its capacity from 12 to 16 beds."All of that was developed to keep people out of the emergency departments," Norman said. "But the key is the individual not going to the emergency department to begin with, because once they go to the ED there's a 50 percent chance that they're going to be admitted to Cherry Hospital."Hospitals adaptHospitals in the region say they've adapted as best they can.Stephanie Herron, nurse manager of emergency services at Brunswick Novant Medical Center, said that when a patient comes in, he or she is triaged by a nurse, medically screened by an ER physician, and if having a psychiatric crisis, seen by a psychiatrist via Web cam within 30 minutes. The psychiatrist and attending physician then consult on the proper treatment, which could be release to outpatient care or to a psychiatric hospital.It can be difficult finding appropriate services at times, Herron said, leading to wait times in the emergency room.New Hanover Regional Medical Center spokeswoman Erin Balzotti said the hospital has a similar process for caring for patients experiencing a mental health crisis. But, she said, "clearly more resources are needed" to serve the population. HHS' Henry said an electronic database of available public and private psychiatric beds statewide has been established in the eastern part of the state. Work is ongoing to implement it statewide, she said.Angie Fisher, director of clinical improvement at Brunswick, said the hospital has seen a steady rise in the number of patients presenting at the emergency department with mental health or substance abuse issues, or both, over the last pive years. She said many factors are at play.The 'perfect storm'Grigas called it the "perfect storm" with the confusion caused by continued transition of mental health services to private agencies, closure of the Tri-County Center Crisis Station in 2008 - it was two years before RHA opened The Harbor - and the continued shutdown of psychiatric beds as part of the state's shift toward community-based care.Still, Amy Myers, the hospital's spokeswoman, said the addition of tele-psychiatry two years ago has helped ER physicians make better decisions about patients presenting with mental health complications."The ER physicians were making the best evaluations they could and often erring on the side of caution and recommending inpatient care when sometimes it might not have been necessary," Myers said.But a doctor's decision to release a patient back home is often difficult to stomach for family members concerned about a loved one they believe to be sick.Jenkins said ER physicians and psychiatrists working from the other side of a camera don't always see what the family has been experiencing, so the individual is released and ends up in the emergency room again in a matter of days or weeks."That's the ring around the rosie," Jenkins said.

In July, the N.C. Department of Health and Human Services began tracking wait times in emergency departments for individuals later placed in a state-run psychiatric hospital. Some 340 individuals from the counties managed by CoastalCare - Brunswick, New Hanover, Pender, Onslow and Carteret - waited on average about 54 hours for placement in a state-run hospital between July and December. Almost all of these individuals were headed to Cherry Hospital in Goldsboro.But even from the first quarter measured (July to September) to the next (October through December), wait times jumped 32 percent, from averages of about 47 hours to 62 hours.The following represents the number of patients and average hours they waited in CoastalCares's service territories to find placement at a public psychiatric institution, mostly Cherry Hospital, by month from July to December. The state is currently constructing an expanded, new Cherry Hospital near the existing campus with the goal of cutting down wait times.CoastalCare is an area authority that functions similarly to an insurance agency for Medicaid recipients in need of mental health services.July57 patients/44 hoursAugust59 patients/34 hoursSeptember55 patients/64 hoursOctober63 patients/50 hoursNovember48 patients/56 hoursDecember57 patients/80 hours